Cholangiocarcinoma surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Suveenkrishna Pothuru, M.B,B.S. [2]

Overview

The predominant therapy for cholangiocarcinoma is surgical resection. Surgical resection of tumors with negative margins is the best option for all subtypes of cholangiocarcinoma although it is only achieved in less than 50% of cases.

Surgery

Surgical exploration may be necessary to obtain a suitable biopsy and to accurately stage a patient with cholangiocarcinoma. Laparoscopy can be used for staging purposes and may avoid the need for a more invasive surgical procedure, such as laparotomy.[1][2] The options for the treatment of cholangiocarcinoma are limited and associated with high rates of perioperative mortality, recurrence, and short survival times. Surgical resection of tumors with negative margins is the best option for all subtypes of cholangiocarcinoma although it is only achieved in less than 50% of cases.

  • Curative resection, or resection of tumor-free surgical margins (R0), remains the best chance for long-term survival, and lymph node status is the most important prognostic factor following R0 resection.
  • Routine lymphadenectomy at the time of surgical resection has been proposed in order to increase the chance of survival. However, it can be omitted in patients with solitary, small peripheral cholangiocarcinoma because the probability of lymph node metastasis is very low.
  • Surgical resection is not recommended for cholangiocarcinomas in patients with primary sclerosing cholangitis because the recurrence rate is very high, close to 90%.

Intrahepatic cholangiocarcinomas

  • In intrahepatic cholangiocarcinomas, resection has usually been indicated in patients with a solitary tumor and with no underlying hepatic disease.
  • Some studies have concluded that major hepatectomy for intrahepatic cholangiocarcinoma is also indicated in selected cirrhotic patients because the overall morbidity, hospital mortality rates, and the appearance of liver failure and other complications (superficial wound infection, abscesses, sepsis, pancreatic leakage, delayed gastric emptying, or biliary leakage) are similar in patients with and without cirrhosis.

Extrahepatic cholangiocarcinomas

  • Resection is an appropriate treatment, depending on the extent in the biliary tree and hepatic vasculature.
  • Resection is usually reserved for extrahepatic cholangiocarcinomas which is restricted to one lobe and without metastasis and abnormal liver function.
  • Tumor ablation performed percutaneously with sonographic guidance using radiofrequency or microwave energy is usually reserved for nonoperable tumors up to 5 cm in size.

Biliary Stent

  • Biliary stent is usually reserved for patients with non-operable cholangiocarcinoma.
  • It is performed percutaneously.
  • Plastic stents require to be changed every 3 months and metal stents could be maintained for longer times.
  • Metal stents are preferred rather than plastic stents because of rapid biliary decompression and a low complication rate after insertion.

Liver Transplant

  • Liver transplantation is usually reserved for patients with cholangiocarcioma with either:[3][4]
    • Perihilar cholangiocarcinoma in the early stages, which cannot be removed surgically
    • No detected metastase
    • Tumors developed in livers with reduced function or underlying a biliary inflammation pathology, such as primary sclerosing cholangitis

References

  1. Weber S, DeMatteo R, Fong Y, Blumgart L, Jarnagin W (2002). "Staging laparoscopy in patients with extrahepatic biliary carcinoma. Analysis of 100 patients". Ann Surg. 235 (3): 392–9. PMID 11882761.
  2. Callery M, Strasberg S, Doherty G, Soper N, Norton J (1997). "Staging laparoscopy with laparoscopic ultrasonography: optimizing resectability in hepatobiliary and pancreatic malignancy". J Am Coll Surg. 185 (1): 33–9. PMID 9208958.
  3. Darwish Murad S, Kim WR, Harnois DM, Douglas DD, Burton J, Kulik LM, Botha JF, Mezrich JD, Chapman WC, Schwartz JJ, Hong JC, Emond JC, Jeon H, Rosen CB, Gores GJ, Heimbach JK (2012). "Efficacy of neoadjuvant chemoradiation, followed by liver transplantation, for perihilar cholangiocarcinoma at 12 US centers". Gastroenterology. 143 (1): 88–98.e3, quiz e14. doi:10.1053/j.gastro.2012.04.008. PMC 3846443. PMID 22504095.
  4. Pascher A, Nebrig M, Neuhaus P (2013). "Irreversible liver failure: treatment by transplantation: part 3 of a series on liver cirrhosis". Dtsch Arztebl Int. 110 (10): 167–73. doi:10.3238/arztebl.2013.0167. PMC 3607086. PMID 23533548.

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